A rotator cuff repair reattaches torn rotator cuff tendons to the humerus. The rotator cuff is made up of four tendons, the supraspinatus, infraspinatus, teres minor and subscapularis, and a tear may involve one or several of them.
If you are still working out whether you have a tear and what it means, start with the rotator cuff tears page. This page covers the operation itself.
The procedure
The repair is performed arthroscopically, through small keyhole incisions. Anchors carrying sutures are screwed into the bone, and the sutures are used to draw the torn tendon back down onto its footprint on the humerus so it can heal to bone.
A double-row repair spreads the fixation over a larger area of bone, which increases the contact area between tendon and bone.
Risks and complications
Every operation carries risk. The figures below are the ones Dr Cutbush discusses in consultation, so you can weigh them before deciding. Arthroscopic surgery carries lower rates of most of these than open surgery.
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Bruising and haematoma. Varies between people and resolves with time.
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Infection. Approximately 1 in 300.
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Frozen shoulder. Approximately 5%. It is usually mildly stiff and painful, improves over a few months, and can act as an internal splint while the repair heals.
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Retear. Reported in up to 40% of repairs across published series, depending heavily on tear size, tendon quality and how well the shoulder is protected afterwards.
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Nerve injury. Approximately 1 in 4,000.
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Anaesthetic risk. Mortality from general anaesthetic in Australia is approximately 1 in 100,000.
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DVT and pulmonary embolism. Blood clots in the legs or lungs. Recognised and treated promptly, the risk of serious consequences is greatly reduced.
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Wound problems. Usually superficial, occasionally requiring a small intervention.
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Swelling in the arm and shoulder from sling use. This usually settles quickly but can persist for several months.
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Numbness or tingling in the fingers. Caused by stretch on the ulnar nerve at the elbow when the elbow sits at 90 degrees in a sling. Straightening the elbow periodically and loosening the sling strap usually relieves it.
Before surgery
- Confirm with your health fund that the hospital fee is covered, and confirm the anaesthetist's fees.
- Register with the hospital, complete and return the paperwork, and arrange transport, as you cannot drive yourself home.
- Arrange any recommended pre-operative physiotherapy or pathology tests, such as blood tests.
- Use benzoyl peroxide 5% wash on the shoulder for five applications: twice daily for two days, then once on the morning of surgery. This reduces the risk of infection from Cutibacterium acnes, a bacterium that lives in the skin around the shoulder.
- Pack a hospital bag: medications in their original packaging, a loose button-up shirt, nightwear, toiletries, and your CPAP machine if you use one.
- Ask the office when to stop any blood thinners, and ask your anaesthetist about diabetic medication.
- Confirm admission details with the office one to two business days before surgery.
The day of surgery
Admission details are confirmed one to two business days beforehand. Admission can be as early as 6am, so patients travelling from outside Brisbane are usually advised to stay the night before. See our accommodation options.
After admission the anaesthetist will see you before the general anaesthetic. Dr Cutbush will greet you and mark the operative site.
The stay is usually one night. Dressings are changed the morning after surgery and discharge is usually around 10am, after a review with Dr Cutbush. You will be given a post-operative folder containing your operation letter, rehabilitation information and aftercare instructions. Arrange for someone to take you home.
Recovery and healing
You will wear a sling for six weeks and will not be able to drive during that time. You will need time off work and recreational activity; returning to work can take up to three months depending on what your work involves.
How the repair heals
Healing between tendon and bone is the critical phase. A clot forms at the repair site, fibroblasts move in and lay down collagen, and most of that collagen is deposited in the first four to six weeks. The new collagen fibres are then remodelled so they run parallel and can carry load. Remodelling takes six to twelve months in total, is fastest between weeks four and twelve, and is largely complete by four to six months.
Light loading and light physiotherapy assist remodelling. This is why the rehabilitation programme increases gradually rather than all at once.
Follow-up
Reviews with Dr Cutbush take place at 6 weeks, 12 weeks, 6 months, 12 months and 24 months. An MRI may be requested before some of these reviews.
Rehabilitation
Rehabilitation after a rotator cuff repair is complex and benefits from an experienced physiotherapist. It is typically the longest rehabilitation of any shoulder procedure, taking six to twelve months.
The shoulder is generally protected for the first three months while the repair heals.
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Weeks 1 to 6: sling full time.
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Weeks 7 to 12: for large tears at risk of retear, a further six weeks of partial sling use may be advised, worn when leaving the house. Full-time sling use for the whole 12 weeks is rarely recommended.
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From week 7: if the sling is no longer needed, exercises increase slightly but stay light, aimed at restoring range of motion.
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At 12 weeks: light strengthening may begin, depending on the MRI findings.
MRI at 6 and 12 weeks checks the integrity of the repair and guides how quickly rehabilitation progresses.
Physiotherapy guidelines
Day one. The hospital physiotherapist will show you how to fit the sling and how to manage eating, showering and dressing. Tendons have a poor blood supply, and reasonable healing takes at least 12 weeks, which is why the early restrictions matter so much.
Phase one, early healing and protective. Strict passive exercises only. The sling is worn at all times except when washing or doing exercises. No active shoulder movement, no lifting, no weight bearing through the arm, and no tucking in shirts. A pillow under the elbow can help with sleep. Ice and a correctly fitted sling help with pain.
Day one exercises, started in hospital:
- Passive pendulum, letting the arm hang and move without swinging the body
- Passive forward lean, generally limited to about 120 degrees, with modifications for large tears or subscapularis repairs
- Passive external rotation, generally to about 20 degrees, or 0 degrees for subscapularis repairs
- Elbow flexion and extension, four times daily
- Gentle wrist and hand movement, avoiding forceful gripping
- Neck movement and gentle shoulder blade exercises
Follow-up: see a local physiotherapist in the first one to two weeks.
Results after surgery
Published series report good to excellent results in approximately 90 to 95% of patients, with improvement in pain and function usually seen within six months. Individual results vary, and the factors below make a real difference.
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Following the protocol. Excess stress on the shoulder during recovery can cause the repair to fail. This is the single factor most within your control.
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Degenerative change. Long-standing tears can lead to muscle wasting, fatty replacement of the muscle and arthritis. Significant arthritis is a contraindication to this surgery.
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Tear size. Large tears place more strain on the sutures, are technically more difficult, may have retracted, and in some cases are too scarred to restore.
Next steps
Surgery is only ever considered after assessment and discussion of the alternatives. If you have been told you may need a rotator cuff repair, or you want a second opinion, you will need a referral from your GP to claim the Medicare rebate.
This page is general information about a surgical procedure and is not a recommendation that you have it. Whether surgery is appropriate for you can only be determined after assessment. All surgery carries risk; the risks relevant to you are discussed in consultation before any decision is made.
